Mental Wellbeing Before, During And After Pregnancy

World Maternal Mental Health Day, celebrated on 2 May 2018, aims to spread the awareness of mental or psychiatric disorders that are prevalent in the perinatal period (the first 1 000 days of life), to ensure access to mental health care during this vulnerable time. Maternal Mental Health shouldn’t just be thought of in May, but all year round. Untreated disorders affecting the mother at this time can have harmful effects on the infant, which is why early detection – and intervention – is important.

Maternal mental health is the mental and emotional well-being of a woman from conception, through pregnancy, to the postpartum period, including the first 1 000 days – known as the perinatal period – of the infant’s life. According to Dr Lavinia Lumu, specialist psychiatrist, Akeso Crescent Clinic, Randburg, many mothers experience some form of depression, anxiety or other psychiatric disorder during pregnancy, or in the 12 months after childbirth.

“Approximately one in five new mothers worldwide, and up to one in three in South Africa, may experience symptoms without even realising it. Psychiatric disorders in the perinatal period, such as anxiety or depression, are often missed or left untreated to the detriment of mother and baby. Research shows that treatment is beneficial for both, and for the family as a whole.”

Women are more prone to develop psychiatric disorders in the perinatal period because of the physiological changes, including hormonal fluctuations, which occur during pregnancy. Other factors such as poverty, migration, extreme stress, exposure to violence (domestic, intimate partner, sexual and gender-based), conflict situations, natural disasters, and low social support may also increase the risks for the development of a psychiatric disorder.

1. Perinatal depression

Perinatal depression can occur at any time from preconception, to the peripartum/perinatal period to the postpartum/postnatal period, for up to 12 months after birth. It is characterized by a low or depressed mood, lack of interest, drive and motivation, or the inability to feel pleasure (anhedonia) for at least two weeks. Other symptoms include difficulty sleeping, changes in appetite, fatigue, excessive crying, anxiety, irritability, decreased concentration and impaired memory, and feelings of guilt.

“Feeling hopeless or overwhelmed, having thoughts of death or suicide, and losing interest in the baby or feeling like you can’t bond are also among the symptoms of perinatal depression,” says Dr Bavi Vythilingum, specialist psychiatrist, Akeso Kenilworth Clinic, Cape Town. “Overall, the individual feels that she has difficulty functioning at the level she feels is right for her.”

2. Bipolar disorder

A more serious mood disorder is bipolar disorder, which may present with either a depressive or a manic/hypomanic or mixed episode. Common manic/hypomanic symptoms include an elevated o irritable mood, a decreased need for sleep, being excessively talkative, thoughts racing through your head, impulsivity and psychosis. “Psychosis in mothers may manifest as either auditory or visual hallucinations, delusions, suicidal thoughts or thoughts of harming the baby, known as infanticide,” says Dr Vythilingum. “This is an emergency and women who experience these feelings should seek help immediately.”

3. Anxiety

Anxiety is characterised by excessive fear and worry that results in symptoms that interfere with daily functioning. In pregnancy, the excessive release of endogenous cortisol (stress hormone), due to severe anxiety, may interfere with the normal growth of the unborn foetus. Symptoms include excessive and constant worrying, fatigue, headaches and muscle pain, insomnia, and poor concentration or impaired memory.

Panic symptoms that may lead to panic or anxiety attacks vary from shortness of breath and chest pain, to tingling sensations (skin crawling), dizziness and blurry vision. These typically peak within a few minutes and resolve within 30 minutes to an hour. “It’s important that common medical conditions which often have their onset during pregnancy, such as hyperthyroidism, asthma, and pregnancy- related heart conditions are excluded, so that the patient can be properly diagnosed,” says Dr Lumu.

4. Birth trauma

If childbirth is experienced as traumatic, especially if there are obstetric complications (excessive tearing or bleeding, complications with the baby, miscarriage) or excessive pain, it may be followed by post-traumatic stress disorder (PTSD), and is referred to as birth trauma or postpartum PTSD.

“International research is limited but it is estimated that the percentage of women who experience delivery as traumatic is between 9% and 44%,” says Dr Lumu. “Approximately 9% to 15% of these women experience PTSD following childbirth. For the diagnosis of PTSD to be made, symptoms must be persistent at least for one month after childbirth. “These included recurrent and involuntary memories or thoughts and re-experiencing the birth itself, flashbacks or nightmares, avoidance of things associated with the birth (including avoiding the baby) difficulty breastfeeding, problems with sexuality, requests for an elective caesarean section in a subsequent pregnancy, as well as anxiety and a persistent feeling of being on edge.”

5. Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) manifests as intrusive, unwanted thoughts (obsessions) that are distressing, accompanied by repeated behaviours or rituals (compulsions) to decrease the anxiety of the intrusive thoughts. The thoughts and behaviours become distressing and interfere with day-to-day functioning.

“Common examples of obsessions include an intense fear that something is contaminated by germs or dirt,” Dr Lumu explains. “Women with perinatal OCD often worry that their baby will be harmed through contamination. The compulsions may include washing, cleaning or sterilising repetitively and excessively. This can take up so much time that it interferes with daily functioning. Other examples include repeatedly checking up on the baby throughout the night to ensure that it is breathing. Severity of OCD symptoms may also result in the mother avoiding the baby altogether.”

What are the risks posed by disorders?

Perinatal psychiatric disorders, if untreated, can result in high-risk outcomes such as psychosis and suicide or infanticide. “A decline in functioning of a new mother may lead to child neglect,” cautions Dr Vythilingum. “Babies of mothers who have had untreated psychiatric disorders are also at high risk of developing behavioral, emotional, and mental health problems later on in life. Treatment can ensure that these risks disappear.”

Management of maternal mental health problems

The mother’s partner or family are usually the first to identify symptoms of a potential disorder. Assisting the new mother with urgent screening and intervention is imperative. Help can also include caring for the baby and other children, and assisting with household duties. “If a family member suspects that a new or expectant mother has a mental health problem, it is important to encourage her to seek help urgently from a healthcare professional, such as a psychologist, psychiatrist, midwife, GP, or obstetrician,” advises Dr Lumu.

“Milder depressive conditions can be managed through psychotherapy, while more severe conditions require pharmacotherapy in the form of antidepressants for depression and anxiety. Many antidepressants have been well researched and have been shown to be relatively safe during pregnancy and breast-feeding.”

Serious psychiatric disorders that occur in pregnancy should be referred to a psychiatrist. “In some instances, hospital admission or electroconvulsive therapy (ECT) may be indicated,” says Dr Vythilingum ECT is a safe and effective treatment for serious psychiatric disorders in pregnancy.”

Ultimately, a multi-disciplinary approach involving all healthcare practitioners is essential in ensuring optimal outcomes for mother and baby. Given the enormous changes that occur on becoming a new parent, it’s vital that mental health and wellbeing issues are dealt with as an important part of caring for new mothers and mothers-to-be. For more information, visit the www.akeso.co.za or the South African Depression and Anxiety Group (SADAG) at www.sadag.org

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